Your PDPM Questions Answered – Part 5: Assessment Requirements

Your Questions on PDPM’s Assessment Requirements

• Q: Suppose a resident is admitted late on a Friday and discharges early on a Sunday, are we liable for not setting the SNF PPS 5-day prior to discharge?

  A: If a person discharges on or before the 8^th day and no 5-day assessment has been opened. The provider can bill default. This is unchanged from current policy. CMS’ long standing policy is that the 5-day assessment must be opened prior to the resident’s discharge.

• Q: How has the regulation changed for late 5 day assessment? Primarily concerned with late notification of change of payor such as managed care.

  A: Based on the Draft RAI 3.0 Manual v 1.17 (effective 10/1/19) the policy appears to have been changed in which default would have to be billed if there is no 5-day assessment or the 5-day assessment is late. This appears to be a significant change to current policy in which there is the option for the provider to use the HIPPS code from the OBRA Admission assessment, if completed. These instructions are no longer included in the Draft manual. This may be due to the fact that Section GG does not appear on an Admission assessment so therefore no PDPM HIPPS code would be calculated.

  It is expected that further changes to the Draft RAI manual will be forthcoming. We are also waiting for updates to the Medicare Claims Processing Manual for further guidance on billing under PDPM.

• Q: If the SNF PPS 5-day is opened and resident is discharged, can we still change the date to match the D/C as we do currently?

  A: Yes, this policy has not changed.

• Q: Can the SNF PPS 5 day MDS still be modified?

  A: Yes, the only change to the Correction Policy is the timeframe allowed to make corrections. CMS is changing this from 3 years to 2 years.

Interrupted Stay Policy

• Q: Does the reason for returning need to be related to the initial stay (for interrupted stay)?

  A: No, the reason for returning is not a deciding factor.

• Q: Under the definition of an interrupted stay, it does not matter if the patient was discharged inpatient to the hospital or observation, is that understanding correct?

  A: Correct. For purposes of determining if it is an interrupted stay it would not matter if they were at the hospital under observation or if they were admitted as in inpatient.

• Q: Do you complete an Entry Tracking record with an interrupted stay?

  A: The rules for completing an Entry Tracking record are not changing. If an OBRA Discharge assessment is completed, then a new Entry Tracking record is required upon readmission.

• Q: Will Interrupted stay days be considered skip days?

  A: Technically yes, they are not considered part of the residents 100 days. If a person is discharged to the hospital on day 25, this day now becomes a non-covered day and the day they return would be the new day 25.

• Q: For the ‘no interrupted stay’ we wouldn’t do a new Admission, correct?

  A: The decision to complete a “New” OBRA Admission assessment is based on the type of OBRA Discharge assessment you completed. Assuming an initial OBRA Admission assessment had already been completed, then a new OBRA Admission assessment would be required if they were Discharged Return Not Anticipate (DCRNA) OR if they were Discharged Return Anticipated (DCRA)and did not return within 30 days.

  The rules related to OBRA Admission assessments are not changing due to the implementation of PDPM.

• Q: What happens if they are not admitted to the hospital but is under observation for 3 days?

  A: If they are gone more than 24 hours, then you would complete an OBRA Discharge assessment. Whether they are admitted to the hospital or under observation is not the deciding factor on determining an “interrupted stay”.

• Q: How are your interrupted stay days paid? If we don’t end the PPS, does it act like a skip day for billing?

  A: If a person is discharged to the hospital, then the facility would not get paid for those days, just like current policy. If the resident ended their Medicare Part A stay, and remained in the facility, then you would bill the appropriate payer (Medicaid, Private, etc.).

• Q: When a resident returns after a hospital admission and is an interrupted stay, you did an OBRA Discharge, so when they return do you just do the Entry Tracking record?

  A: Yes, if the Admission assessment had already been completed and the resident was DCRA, then only a new Entry Tracking record is required upon return from the hospital. As always, we would assess for the need to complete a Significant Change in Status assessment and a potential Interim Payment Assessment.

• Q: If a resident is Med A, discharges to the hospital and is gone greater than 24 hours, a PPS Discharge and OBRA Discharge assessment is required, but what if they come back on day 3?

  A: This question cites current rules. Under new PDPM rules and the interrupted stay policy, a SNF PPS Discharge would not be completed if the resident returned within the 3-day interruption window. The OBRA Discharge assessment would still be completed if the individual was admitted to the hospital or if the observation stay was >24 hours.

• Q: For the resident that discharges home (DCRNA) and returns in 2 days, I know I would not need a new 5-day, but would I still need a new OBRA Admission assessments since they discharged return not anticipated?

  A: Yes, that is correct. Since they were Discharged Return Not Anticipated (DCRNA) then a new OBRA Admission assessment would be required.

• Q: How will I know if a resident is admitted to another SNF if they discharged home from my facility? And vice versa – how will I know if my admission came from another SNF, then home, then my SNF?

  A: It is not really important to know if they are admitted to another SNF. If they do not return to YOUR SNF within 3 days, then the interruption policy does not apply.

  If a person is admitted to YOUR SNF who was previously at another SNF, they are treated as a new Admission.

  The interrupted stay policy only applies to residents who are readmitted and/or resume Part A covered services in the SAME SNF.

• Q: If they are admitted to the hospital and readmit on day 3, we would need an OBRA Discharge assessment and not a PPS Discharge assessment correct? Do they need GG’s for an interrupted stay?

  A: You would only complete an OBRA Discharge assessment since they were admitted to the hospital. Since they meet the criteria for an “interrupted stay” a SNF PPS Discharge is not required. Section GG would not be needed unless an IPA assessment is completed. Section GG is only completed on SNF PPS 5-day assessments, IPA assessments, and SNF PPS Discharge assessments.

• Q: Did you say to do an Entry Tracking record on someone coming back from hospital on an IPA?

  A: Entry Tracking record requirements are unchanged with the implementation of PDPM. An Entry Tracking record is required for new admissions and anytime a person is readmitted following the completion of an OBRA Discharge assessment.

• Q: During an interrupted stay do the days missed count as part of 100 days? I noticed you mentioned doing an Entry Tracking upon re-admit so I assume the days missed are not part of the 100 days, correct?

  A: No, the days under an interrupted stay do not go against the 100 Medicare days. The Entry Tracking record is required since you would had completed an OBRA Discharge assessment and the resident was subsequently readmitted to the SNF.

• Q: Are new therapy evaluations required in non-interrupted and interrupted stays?

  A: If it is an “interrupted stay” then it is considered a continuation of the Medicare stay and no new SNF PPS 5-day assessment is completed. New therapy evals would also not be required. If it is not an “interrupted stay” then it is considered a new Medicare stay and a new SNF PPS 5-day assessment is completed. This would require completion of new therapy evaluations.

  See CMS PDPM FAQ document.

• Q: On the last case study for Mrs. Bartz. Would you also do an OBRA Admission assessment with the new SNF PPS 5-day assessment or not since it is the same episode?

  A: In the case study related to Mrs. Bartz, a new OBRA Admission assessment is not required since it was completed previously, she was discharged return anticipated and was not out of the facility for more than 30 days.

• Q: Resident was out of facility 2 days, considered an interrupted stay, we still do the OBRA Discharge (DCRA), but not SNF PPS Discharge? Then the Entry Tracking record?

  A: Yes, that is correct. The OBRA Discharge is still required. Since you completed an OBRA Discharge, you would then need to complete a new Entry Tracking record upon readmission to the SNF. The SNF PPS Discharge assessment would not be completed since it is considered an interrupted stay.

Interim Payment Assessment (IPA)

• Q: In regards to the IPA, if therapy ends and we continue to skill the resident under nursing, would we be expected to complete the IPA assessment to reflect that the resident is no longer receiving therapy?

  A: No. An IPA assessment is not required. IPA assessments are strictly optional. There are no required rules for completion. Under PDPM payment is not based on whether a person is receiving therapy or the amount of therapy.

• Q: Where do you find a PDPM grouper?

  A: CMS provides a PDPM Grouper on their website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

• Q: So, the IPA new rate is subjected to the 2% decrease if the IPA ARD is on day 21 or later, correct?

  A: Yes, that is correct. IPA assessments do not change the variable per diem adjustments. The 2% decrease in the PT and OT components still occur every 7 days beginning on day 21.

• Q: Do we have a ‘sample’ of the Item Set for the IPA?

  A: All the MDS items sets for 10/1/2019 are on the CMS website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html

• Q: Would an IPA be used for an EOT, SOT or COT?

  A: No. For Medicare purposes, EOT, SOT, and COT assessments will no longer exist as of 10/1/2019. No assessments are required when there is an end of therapy, start of therapy, or a change in therapy intensity.

• Q: How many IPA assessments can you do for one resident?

  A: There is no limit.

• Q: The VPD payment adjustments for IPA does not reset, but does it delay the reduction schedule by the amount of days the resident was out of the facility? Like skip days?

  A: Yes, the VPD payment adjustments are based on Medicare days, not calendar days to correspond to the 100 days of Medicare.

PPS Discharge Assessments

• Q: So no more NPE assessments?

  A: A SNF PPS Discharge assessment uses the NPE item set. NPE=SNF PPS Discharge assessment

• Q: So now we are doing an OBRA Discharge and a SNF PPS Discharge for MCR?

  A: Depends on the circumstances. If the individual is physically discharged from the facility, then an OBRA Discharge assessment is required (same as current policy). If they do not return within the 3-day interruption window, then a SNF PPS Discharge assessment is also required.

  If the individual is not physically discharged from the facility at the termination of their Medicare Part A stay, then only SNF PPS Discharge assessment is completed (as long as they do not resume Part A covered services within the 3-day interruption window). An OBRA Discharge assessment would not be completed since the individual was not physically discharged.

• Q: Can we still combine the OBRA Discharge to the hospital with the SNF PPS Discharge assessment–like we do now?

  A: Yes, this is still an allowable combination. You can combine the OBRA Discharge and the SNF PPS Discharge if both are required and the rules for combining are met.

• Q: Is it best practice to wait 3 days to complete any discharges/PPS discharges?

  A: Under PDPM, it will be a best practice. You will need to determine if the absence from the facility meets the interrupted stay definition or not.

• Q: What if the SNF already completed and submitted a SNF Part A Discharge assessment for a resident that discharged from Part A but was discharged to the hospital after coming off Part A and met the Interrupted stay policy?

  A: In this circumstance the SNF PPS Discharge would not be warranted and the assessment should be modified.

• Q: If a resident on Part A discharges to home an OBRA Discharge is completed. If they do not return within the 3 days do I then need to complete the PPS Part A Discharge?

  A: Yes. You could just combine that with the OBRA Discharge assessment.

• Q: How long do we have to open the ARD for the PPS Discharge assessment now that we have to wait for the interrupted definition?

  A: Per CMS long standing policy, the ARD of the PPS Discharge assessment can be set anytime during the completion period. A SNF PPS Discharge assessment is required to be completed no later than 14 days after the date at A2400C (End Date of Most Recent Medicare Stay).

Other Assessment Related Questions

Q: What will the Sig Change be considered if it is no longer considered an Unscheduled PPS assessment?

A: A Significant Change Assessment (SCSA) will be considered strictly an OBRA assessment and have no impact on payment. The rules for completing a SCSA are not changing under PDPM.

Q: If we are only a skilled unit with no Medicaid, no long term residents, are we required to follow OBRA guidelines? I have heard both yes and no. My state is Texas.

A: OBRA assessments are required for ALL residents in a Medicare and/or Medicaid certified bed. If your beds are SNF beds then I will assume they are Medicare certified and the OBRA assessment schedule must be followed.